Digestive Diseases and Sciences

https://doi.org/10.1007/s10620-020-06414-z

ORIGINAL ARTICLE

Elimination of Dietary Triggers Is Successful in Treating Symptoms

of Gastroesophageal Reflux Disease
Cesare Tosetti1,4 · Edoardo Savarino2 · Edoardo Benedetto1,3 · Rudi De Bastiani1,5 on behalf of the Study Group for
the Evaluation of GERD Triggering Foods

Received: 28 March 2020 / Accepted: 14 June 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Background The relationship between aliments and pathophysiological abnormalities leading to gastroesophageal reflux dis-
ease (GERD) symptoms elicitation is unclear. Nevertheless, patients often report symptoms after ingestion of specific foods.
Aims To identify in primary care setting the presence of foods able to trigger GERD symptoms, and evaluate whether a
consequent specific food elimination diet may result in clinical improvement.
Methods Diagnosis of GERD and quantification of reflux symptoms were done according to GERD-Q questionnaire (posi-
tive when > 8). During clinical data collection, patients were asked to report aliments associated with their symptoms. Also,
a precompiled list of additional foods was administered to them. Then, patients were requested to eliminate the specific
foods identified, and to come back for follow-up visit after 2 weeks when GERD-Q questionnaire and clinical data collec-
tion were repeated.
Results One-hundred GERD (mean GERD-Q score 11.6) patients (54 females, mean age 48.7 years) were enrolled. Eighty-
five patients reported at least one triggering food, mostly spicy foods (62%), chocolate (55%), pizza (55%), tomato (52%),
and fried foods (52%). At follow-up visit, the diagnosis of GERD was confirmed in only 55 patients, and the mean GERD-Q
score decreased to 8.9. Heartburn reporting decreased from 93 to 44% of patients, while regurgitation decreased from 72 to
28%. About half of the patients agreed to continue with only dietary recommendations.
Conclusions Most patients with GERD can identify at least one food triggering their symptoms. An approach based on
abstention from identified food may be effective in the short term.

Keywords Gastroesophageal reflux disease · Primary care · Food · Symptoms · Heartburn · Regurgitation

Background a relevant number of these subjects do consult their Gen-

The presence of typical symptoms (i.e. heartburn and
regurgitation) of gastroesophageal reflux disease (GERD)
is very common in the general population, pertaining about
20–25% of the individuals in Western Countries [1, 2]. Thus,
eral Practitioner, particularly when their symptoms influ-
ence their daily life [3]. The main mechanism involved in
symptom elicitation is represented by the inappropriate
relaxation of the lower esophageal sphincter with consequent
migration of gastric contents into the esophagus [4, 5], but

2
* Edoardo Savarino Gastroenterology Unit, Department of Surgery, Oncology
edoardo.savarino@unipd.it and Gastroenterology – DiSCOG, University of Padova, Via
Giustiniani, 2, 35128 Padova, Italy
Cesare Tosetti
3
tosetti@libero.it Primary Care Gastroenterologist, National Health System,
Cosenza, Italy
Edoardo Benedetto
4
edoardo4@gmail.com Department of Primary Care Porretta Terme, Health Agency
of Bologna, Bologna, Italy
Rudi De Bastiani
5
rudeba@libero.it Department of Primary Care, Heath Agency of Belluno,
Feltre, Italy
1
National Health System, Group for Primary Care
Gastroenterology (GIGA-CP), Belluno, Italy

13
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 Digestive Diseases and Sciences

others features have been involved in the pathogenesis of this
disease, including poor esophageal clearance and visceral
hypersensitivity (6–9).
Various risk factors have been associated with GERD,
and above all, diet seems to play a major role [10–14]. How-
ever, studies are generally inconclusive to show a clear asso-
ciation between the ingestion of particular aliments and the
occurrence of specific pathophysiological abnormalities [12,
15]. Nevertheless, patients often report the rising of reflux
symptoms after the ingestion of specific alimentary foods [1,
16–24]. For this reason, in presence of typical symptoms, it
is generally recommended to reduce the intake of such foods,
for instance, orange, mint, chocolate, suspected to facili-
tate the symptomatology. This is usually done empirically,
but the right and timely identification of these foods may
positively impact on reflux disease presence and severity,
and it could be also useful in reducing the pharmacological
exposure of this population. Indeed, patients with symptoms
of GERD often start therapies with powerful suppressors of
acid gastric secretion, that are difficult to reduce and stop
[25].
The aim of the present study was to identify the presence
of foods able to elicit typical symptoms of GERD, and to
verify whether a consequent diet modification (i.e. specific
food elimination diet) may result in clinical improvement in
GERD patients evaluated in primary care setting.
Methods
Patients
observational questionnaire-based studies with all the data
de-identified prior to analysis do not require IRB or EC
approval. The study was carried out in accordance with the
Helsinki Declaration.
The study was carried out as part of routine evalua-
tion of the patient. A complete clinical history was col-
lected, including demographics (race, age, gender), body
mass index, medical records, and ongoing treatments. In
these subjects, General Practitioners after having checked
and recorded in a professional database demographic
and anthropometrical data, noted in the individual chart
every food that the patient spontaneously related to typi-
cal GERD symptom occurrence. Moreover, additional
foods were annotated by General Practitioners asking the
patients to look at a precompiled list including foods not
reported spontaneously by patients (Table 1). This list of
possible dietary triggers was compiled based on previous
studies [1, 12, 20, 22, 30, 33], considering also the eating
habits in Italy.
At the end of the first visit, each patient was asked to
eliminate from the diet the foods identified, and to come
back for follow-up visit after 2 weeks. In this period, patient
did not assume antisecretory drugs, but the use antacids or
medical devices on demand was allowed by the study proto-
col. During the follow-up visit, after 2 weeks, the GERD-Q
questionnaire was administered again and was recorded in
the database, together with the statement on the eventual
removal of GERD triggering food and the outcome with
respect to prescription of drugs (gastric acid suppressive
drugs or antacids), endoscopy and/or specialist consultation.

This was a prospective study, carried out between March Table 1  List of foods Alcoholic drinks
specifically subjected to
and October 2019 in twelve General Practitioner outpa- the patient after him/her Chocolate
tients’ clinics, each enrolling consecutive adult patients has spontaneously reported
Citrus fruits
presenting for the first time with typical symptoms of the foods related to his/her
occurrence of typical GERD Coffee
GERD. Diagnosis of GERD and quantification of symp-
symptom Cucumbers
toms were done according to GERD-Q questionnaire that
Fatty foods
has been validated for both diagnosis and follow-up of
Fried foods
reflux disease patients in primary care [26, 27]. In par-
Lettuce
ticular, the GERD-Q questionnaire evaluates symptoms
Meat broth
occurring in the last week and it is included in the pro-
Milk
fessional software that General Practitioners use for the
Peppermint
routine management of the patients. Individuals with a
Peppers
GERD-Q score higher than 8 were enrolled in the study
Pizza
[26, 27]. Patients with known GERD and/or alarm (includ-
Processed meat
ing dysphagia and chest pain) symptoms and/or dominant
Sauces
extraesophageal symptoms, as well as patients in therapy
Soft drinks
with antisecretory drugs for non-GERD reasons (i.e. gas-
Sparkling water
troprotection and dyspepsia) or previously submitted to
Spicy foods
esophagogastroduodenoscopy were excluded. The recruit-
Tea
ment of the study was considered completed upon receipt
Tomato
of the hundredth patient enlisted. According to Italian law,

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Digestive Diseases and Sciences

Statistical Analysis symptoms at baseline, as per inclusion criteria, requiring

investigation with upper endoscopy.
Data anonymously extracted by the clinical file of the
patients were collected in order to create a single database. Correlation Between Foods and Symptoms
Results are reported as absolute frequency and percentage or at Baseline
mean and standard deviation. At univariate analysis, contin-
uous and categorical variables were evaluated with the Stu- Eighty-five patients reported spontaneously at least one
dent t test and Chi-squared test. The Kolmogorov–Smirnov triggering food they believe to cause their typical reflux
test was used to assess the normality of data. Results were symptoms, whereas 88 patients reported at least one spe-
considered statistically significant when p value was lower cific aliment after the use of the precompiled list. Overall,
than 0.05. Analyses were performed using Stata software all patients reported at least one food. Table 4 shows the
(StataCorp LLC, USA). foods identified by the patients with the percentage of the
patients recording it. The foods more frequently associated
with typical reflux symptoms resulted: spicy foods (62%),
Results chocolate (55%), pizza (55%), tomato (52%), fried foods
(52%), alcoholic drinks (50%), citrus fruits (48%), sauces
Overall, 100 patients, whose demographic characteristics (48%), coffee (41%), processed meat and fatty foods (34%).
are reported in Table 2, were included into the study. Fifty- To note, 70 patients reported to be already informed of the
four were females, with a mean age of 48.7 years and with possible benefit of excluding these foods from the diet and
a mean body mass index of 24.8 kg/m2. Table 3 reports 54 patients reported an attempt to cut out them from the
the results of the GERD-Q Questionnaire administered at alimentay habits.
the first visit. The mean value of the GERD-Q score was
11.6 (range 9–17). None of the 100 patients reported alarm Correlation Between Foods and Symptoms After
the Specific Food Elimination Diet
Table 2  Demographics and risk factors of the 100 patients included
in the study At follow-up visit, after 2 weeks, again, none of the 100
patients reported alarm symptoms. Only 1% of patient
Features
declared not to being able to eliminate the identified trig-
Sex Males 46 gering food, whereas 46% reported to have completely
Females 54 eliminated from the diet the triggering food and, finally,
Age Median 48.7 years 53% suspended it only partially (between 50 and 75%
Range 18–83 years
of the meals). Table 5 shows the results of the GERD-
Body mass index Median 24.8 kg/m2
Range 18.0–38.8 kg/m2
Q Questionnaire administered at follow-up visit. The
Smokers Never 57
mean GERD-Q score was 8.9 (range 3–17) and decreased
Past 5 23.3% between the first and the follow-up visit. Thus, as
Current 38 illustrated in Fig. 1, GERD-Q score resulted positive for
Alcoholic drinks Never 26 the diagnosis of GERD in 55 patients compared to 100
Non-daily intake 62 patients at baseline (p = 0.001). Figure 1 shows the rate of
Daily intake 10
patients complaining of heartburn and regurgitation with

Table 3  Results of the GERD-Q Questionnaire administered at the first visit (100 patients)

Item Never 1 day 2–3 days 4–7 days Mean score (SD)
n (score) n (score) n (score) n (score)

Heartburn 3 (0) 4 (1) 55 (2) 38 (3) 2.3 (0.7)

Regurgitation 9 (0) 19 (1) 47 (2) 25 (3) 1.9 (0.9)
Epigastric pain 7 (3) 19 (2) 35 (1) 39 (0) 2.1 (0.9)
Nausea 18 (3) 8 (2) 16 (1) 65 (0) 2.4 (1.0)
Difficulty to have night sleep due to heartburn or 23 (0) 31 (1) 26 (2) 20 (3) 1.4 (1.1)
regurgitation
OTC medication for heartburn or regurgitation 30 (0) 15 (1) 25 (2) 30 (3) 1.6 (1.2)
Mean total score 11.6 (2.2)

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 Digestive Diseases and Sciences

Table 4  Frequency of spontaneous reports, as a result of a specific 0.9) (p = 0.001), while the score of regurgitation decreased
request and the total frequency of foods triggeing GERD symptoms from 1.88 (SD 0.9) to 0.97 (SD 1.0) (p = 0.001).
in 100 patients
After the follow-up consultation the following outcomes
Food Spontaneous After specific Total were observed: 45% of patients have agreed to continue
report (%) request (%) only following the dietary recommendations, whereas 55%
Spicy foods 41 21 62 of patients started a pharmacological treatment as follows:
Chocolate 37 18 55 39 (70.9% of treated patients) patients with PPI once daily,
Pizza 28 27 55 6 (10.9% of treated patients) with H2 receptor antagonists
Tomato 27 26 53 once daily, and 10 (18.2% of treated patients) with alginate
Fried foods 43 28 52 (6 of these in combination with antisecretory drugs). None
Alcoholic drinks 33 17 50 of the patients was sent to a gastroenterlogy specialist.
Citrus fruit 27 21 48
Sauces 19 29 48
Coffee 19 22 41 Discussion
Processed meat 13 21 34
Fatty foods 13 9 34 There has been speculation for many years about the concept
Meat broth 19 9 28 that certain dietary and lifestyle factors may play a role in
Peppermint 8 19 27 the pathogenesis or course of GERD. However, a wide-rang-
Sparkling water 9 17 26 ing review of the available data reveals conflicting findings
Milk 12 6 18 regarding the impact of most of these factors. In addition, the
Cucumbers 6 9 14 majority of the studies concerned about the small numbers
Peppers 5 8 13 of patients included, the retrospective design, the lack of
Soft drinks 5 6 11 use of validated questionnaires for GERD assessment, the
Lettuce 6 3 9 unclear duration of the follow-up, and because they did not
Others * 26 evaluate concomitant therapy with PPIs and antacids.
Consequently, any advice given on modifying diet and/
*Red meat (4%); walnuts (3%); cabbages, licorice, onions (2%); pota- or lifestyle in the management of GERD represents a form
toes. ice cream, garlic, pickles, beans, artichokes, olives, tea, leg-
umes, almonds, chestnuts (1%) of empirical therapy. Thus, this study was carried out in
subjects presenting for the first time to their General Practi-
tioner because of symptoms of GERD without alarm signs,
a score > 1 (presence of symptoms more than 1 day in the to assess whether it was possible to identify triggering
week). The frequency of heartburn scoring > 1 decreased foods by means of the General Practitioner interview and
from 93 to 44% (p = 0.001), while the frequency of regur- the administration precompiled list of potential triggering
gitation scoring > 1 decreased from 72 to 28% (p = 0.001). aliments. We showed that patients are able to identify at
Figure 2 shows the difference in the mean score for heart- least one food which is considered to cause their symptoms,
burn and regurgitation between the two consultations. The with an increased detection by using a precompiled list of
score of heartburn decreased from 2.3 (SD 0.7) to 1.3 (SD potential triggering foods. Moreover, after 2 weeks of spe-
cific food elimination diet according to the results of the

Table 5  Results of the GERD-Q Questionnaire administered at the control visit (n = 100 patients) after the elimination of the triggering food
from the diet
Item Never 1 day 2–3 days 4–7 days Mean score Significance
n (score) n (score) n (score) n (score) (SD) vs initial visit

Heartburn 19 (0) 37 (1) 37 (2) 7 (3) 1.3 (0.9) < 0.001

Regurgitation 39 (0) 33 (1) 20 (2) 8 (3) 1.0 (1.0) < 0.001
Epigastric pain 3 (3) 12 (2) 28 (1) 57 (0) 2.3 (0.8) NS
Nausea 7 (3) 5 (2) 13 (1) 75 (0) 2.6 (0.9) NS
Difficulty to have night sleep due to heartburn or 62 (0) 22 (1) 14 (2) 2 (3) 0.6 (0.8) < 0.001
regurgitation
OTC medication for heartburn or regurgitation 45 (0) 17 (1) 20 (2) 18 (3) 1.1 (1.2) 0.031
Mean total score 8.9 (2.9) < 0.001

NS as not significant

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Digestive Diseases and Sciences

Fig. 1  Diagnosis of GERD % 100

according the GERD-Q ques-
First visit Control visit
tionnaire (score > 8) and fre-
quency of patients scoring > 1
80
(presence of symptoms > 1 day
in the week) for heartburn and
regurgitation at the first consul-
tation and at the control visit 60

40

20

0
Diagnosc score for GERD Score for heartburn > 1 Score for regurgitaon > 1

Fig. 2  Mean score for heartburn Score

and regurgitation in the first
First visit Control visit
consultation and at the control 3.5
visit after 15 days
3

2.5

1.5

0.5

0
Heartburn Regurgitaon

questionnaire, about half of the patients obtained such a ben-
efit to not require the start of a pharmacological therapy or
to undergo further investigations.
Foods causing GERD symptoms identified by our patients
are quite varied and mostly correspond to what has been
reported in previous studies, in which the foods involved
vary according to the patient’s food habits and the country
in which they live [20]. Anyway, patients’ ability to recog-
nize exacerbating food symptoms has been demonstrated by
investigations in different countries such as Korea [21] and
Tanzania [30]. Although the different studies do not show
univocal results, most of the available data substantially
identify the following foods as exacerbating reflux symp-
toms: fried foods [16, 18, 20–22], spicy foods [1, 16–18,
20, 21, 30], fatty foods [19, 24] and tomato [20, 22, 30].
In contrast, data on coffee consumption are mixed [1, 21,
23, 28, 31, 32], similar to tea [22, 23, 28, 32, 33], citrus
fruit [20, 22] and even alcoholic beverages [1, 16, 20, 22,
28–30]. Data on foods normally cited in dietary recommen-
dations such as chocolate and peppermint [20] are surpris-
ingly scarce.
The results of the studies that have tried to associate
certain foods to specific pathophysiological alterations
able to explain the onset of symptoms of GERD are gener-
ally poorly significant [15, 34]. High-fat meals increase the
esophageal acid exposure as assessed by reflux monitoring
in reflux patients with and without esophagitis [24], reduce
the resting pressure of the lower esophageal sphincter and
prolong the time of gastric emptying [35]. Animal fats and
proteins seem to increase acid secretion and gastrin levels

13

[36], whereas chocolate is considered a food capable of
reducing the tone of the lower esophageal sphincter [15,
37]. A study carried out in 15 patients by means of pH
impedance monitoring and comparing in the same patient
the effects of a meal with a high rate of animal proteins
and those of a meal with a high rate of vegetable proteins
showed that the meal rich in animal proteins was followed
by a greater number of total and acid refluxes [38]. Finally,
it has been shown that the frequency of GERD is lower in
individuals following predominantly a Mediterranean diet
(frequent consumption of composite/traditional dishes,
fresh fruit and vegetables, olive oil, and fish) compared to
those following largely non-Mediterranean diet (frequent
consumption of red meat, fried food, sweets, and junk/
fast food) [39].
More consistent are the data that associated the pres-
ence of GERD with overweight and obesity [12, 15, 40–42]
rather than the different components of the patients’ diet,
and, to confirm, there are studies observing that weight loss
is effective in reducing symptoms and PPI use in GERD
patients [12, 43, 44]. In our study, the mean BMI of the
patients was at the upper limit of the international normal
range and, given the short time follow-up study, it is difficult
to hypothesize that the results on the GERD symptoms, in
absence of a structured diet, were due to a possible mod-
est weight reduction rather than the elimination of one or
more specific foods. However, the lack of solid evidence
between specific foods and pathophysiologic alterations of
the esophagus cannot disregard the importance of clinical
observations reported by the patients.
Our study has some limitations. The short follow-up time,
due to the desire to adapt the General Practitioners behavior
to daily practice as much as possible, does not allow to know
the duration over time of the symptomatic results achieved.
Also in order to carry out a study whose results can be eas-
ily reused in the daily practice, specific questionnaires on
quality of life were not used. Similar, a structured diet pro-
gram was not set in overweight or obese patients. Studies
show that only 12% of GERD patients received documented
counseling on lifestyle modifications [45], while it has been
demonstrated that a dietitian’s first gastroenterology model
of care helps improve patient flow, reduces wait times and
may be useful elsewhere to address outpatient gastroenterol-
ogy service pressures [46]. The same considerations apply
to cigarette smoking, a factor has been considered favoring
reflux symptoms [1, 28, 29].
In conclusion, our study shows that a large number
of GERD patients are able to identify at least one food
triggering their symptoms and that an initial therapeutic
approach based on abstention from identified food may
be effective in the short term. Prospective and controlled
studies designated for longer periods and with a greater
13
Digestive Diseases and Sciences
number of subjects are mandatory to define whether this
approach could determine a lower exposure of patients to
pharmacological therapies, particularly in the long-term.
Acknowledgments Study Group for the Evaluation of GERD Trigger-
ing Foods: Alessandra Belvedere, Carmelo Cottone, Patrizia Gambaro,
Maurizio Mancuso, Enzo Pirrotta, Riccardo Scoglio, Enzo Ubaldi,
Maria Zamparella.
Author contributions CT and ES contributed to study concept, data
collection and analysis, critical review of manuscript, drafting, and
finalization of manuscript; EB and RDB contributed to study concept,
data collection, critical review of manuscript, and finalization of manu-
script; and AB, CC, PG, MM, EP, RS, EU, and MZ contributed to data
collection and critical review of manuscript
Funding None.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All the procedures performed in studies involving
human participants were in accordance with the ethical standards of
the national research committee and with the 1964 Helsinki Declaration
and its later amendments or comparable ethical standards.
References
1. Bolin TD, Korman MG, Hansky J, Stanton R. Heartburn: com-
munity perceptions. J Gastroenterol Hepatol. 2000;15:35–39.
2. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the
epidemiology of gastro-oesophageal reflux disease: a systematic
review. Gut. 2014;63:803–871.
3. Jones R, Ballard K. Healthcare seeking in gastro-oesophageal
reflux disease: a qualitative study. Eur J Gastroenterol Hepatol.
2008;20:269–275.
4. Savarino E, Bredenoord AJ, Fox M, et al. Advances in the physi-
ological assessment and diagnosis of GERD. Nat Rev Gastro-
enterol Hepatol. 2017;14:665–676.
5. Gyawali CP, Roman S, Bredenoord AJ, et al. Classification of
esophageal motor findings in gastro-esophageal reflux disease:
conclusions from an international consensus group. Neurogas-
troenterol Motil. 2017;29:e13104.
6. Frazzoni M, de Bortoli N, Frazzoni L, et al. Impairment of
chemical clearance and mucosal integrity distinguishes hyper-
sensitive esophagus from functional heartburn. J Gastroenterol.
2017;52:444–451.
7. Frazzoni M, Frazzoni L, Tolone S, De Bortoli N, Savarino V,
Savarino E. Lack of improvement of impaired chemical clear-
ance characterizes PPI-refractory reflux-related heartburn. Am
J Gastroenterol. 2018;113:670–676.
8. Gyawali CP, Sifrim D, Carlson DA, et al. Ineffective esopha-
geal motility: concepts, future directions, and conclusions
from the Stanford 2018 symposium. Neurogastroenterol Motil.
2019;31:e13584.
9. Ribolsi M, Gyawali CP, Savarino E, et al. Correlation between
reflux burden, peristaltic function, and mucosal integrity in
GERD patients. Neurogastroenterol Motil. 2020;32:e13752.
Digestive Diseases and Sciences
10. Savarino E, Zentilin P, Marabotto E, et al. Overweight is a risk
factor for both erosive and non-erosive reflux disease. Dig Liver
Dis. 2011;43:940–945.
11. Fass R. Alternative therapeutic approaches to chronic pro-
ton pump inhibitor treatment. Clin Gastroenterol Hepatol.
2012;10:338–345.
12. Ness-Jensen E, Hveem K, El-Serag H, Lagergren J. Lifestyle
intervention in gastroesophageal reflux disease. Clin Gastroen-
terol Hepatol. 2016;14:175–182.
13. Sethi S, Richter JE. Diet and gastroesophageal reflux disease:
role in pathogenesis and management. Curr Opin Gastroenterol.
2017;33:107–111.
14. Dağlı Ü, Kalkan İH. The role of lifestyle changes in gastroe-
sophageal reflux diseases treatment. Turk J Gastroenterol.
2017;28(Suppl 1):S33–S37.
15. Surdea-Blaga T, Negrutiu DE, Palage M, Dumitrascu DL.
Food and gastroesophageal reflux disease. Curr Med Chem.
2019;26:3497–3511.
16. Nebel OT, Fornes MF, Castell DO. Symptomatic gastroesopha-
geal reflux: incidence and precipitating factors. Am J Dig Dis.
1976;21:953–956. https​://doi.org/10.1007/BF010​71906​.
17. Lim LG, Tay H, Ho KY. Curry induces acid reflux and symptoms
in gastroesophageal reflux disease. Dig Dis Sci. 2011;56:3546–
3550. https​://doi.org/10.1007/s1062​0-011-1799-3.
18. Jarosz M, Taraszewska A. Risk factors for gastroesophageal reflux
disease: the role of diet. Prz Gastroenterol. 2014;9:297–301.
19. El-Serag HB, Satia JA, Rabeneck L. Dietary intake and the risk
of gastro-oesophageal reflux disease: a cross sectional study in
volunteers. Gut. 2005;54:11–17.
20. Dibley LB, Norton C, Jones R. Don’t eat tomatoes: patient’s self-
reported experiences of causes of symptoms in gastro-oesophageal
reflux disease. Fam Pract. 2010;27:410–417.
21. Choe JW, Joo MK, Kim HJ, et al. Foods inducing typical gastroe-
sophageal reflux disease symptoms in Korea. J Neurogastroen-
terol Motil.. 2017;23:363–369.
22. Kubo A, Block G, Quesenberry CP Jr, Buffler P, Corley DA.
Dietary guideline adherence for gastroesophageal reflux disease.
BMC Gastroenterol. 2014;14:144.
23. Mehta RS, Song M, Staller K, Chan AT. Association between bev-
erage intake and incidence of gastroesophageal reflux symptoms.
Clin Gastroenterol Hepatol. 2019;S1542–3565(19):31380–31381.
24. Fan WJ, Hou YT, Sun XH, et al. Effect of high-fat, standard, and
functional food meals on esophageal and gastric pH in patients
with gastroesophageal reflux disease and healthy subjects. J Dig
Dis. 2018;19:664–673. https:​ //doi.org/10.1111/1751-2980.12676.​
25. Ljungdalh JS, Rubin KH, Durup J, Houlind KC. Treatment of
newly-diagnosed gastroesophageal reflux disease: a nation-
wide register-based cohort study. Scand J Gastroenterol.
2019;54:830–837.
26. Jones R, Junghard O, Vakil N, Halling K, Wernersson B, Lind
T. Development of GerdQ, a tool for the diagnosis and manage-
ment of gastro-esophageal reflux disease in primary care. Aliment
Pharmacol Ther. 2009;30:1030–1038.
27. Jonasson C, Wernersson B, Hoff DAL, Hatlebakk JG. Validation
of the GerdQ questionnaire for the diagnosis of gastro-oesopha-
geal reflux disease. Aliment Pharmacol Ther. 2013;37:564–572.
28. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle
related risk factors in the aetiology of gastro-oesophageal reflux.
Gut. 2004;53:1730–1735.
29. Nocon M, Labenz J, Willich SN. Lifestyle factors and symptoms
of gastro-oesophageal reflux—a population-based study. Aliment
Pharmacol Ther. 2006;23:169–174.
30. Mwandri MB, Mwita JC, Magafu MG, Kilonzo KG, Urasa SJ.
Risks, precipitants and clinical presentation of gastro-oesophageal
reflux disease at the Kilimanjaro Christian medical centre in Tan-
zania. Pan Afr Med J. 2014;19:119.
31. Kim J, Oh SW, Myung SK, et al. Association between coffee
intake and gastroesophageal reflux disease: a meta-analysis. Dis
Esophagus. 2014;27:311–317.
32. Wei TY, Hsueh PH, Wen SH, Chen CL, Wang CC. The role of tea
and coffee in the development of gastroesophageal reflux disease.
Ci Ji Yi Xue Za Zhi. 2019;31:169–176.
33. Cao H, Huang X, Zhi X, Han C, Li L, Li Y. Association between
tea consumption and gastroesophageal reflux disease: a meta-
analysis. Medicine (Baltimore). 2019;98:e14173.
34. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures
effective in patients with gastroesophageal reflux disease? An
evidence-based approach. Arch Intern Med. 2006;166:965–971.
35. Herregods TV, Bredenoord AJ, Smout AJ. Pathophysiology of
gastroesophageal reflux disease: new understanding in a new era.
Neurogastroenterol Motil. 2015;27:1202–1213.
36. Richardson CT, Walsh JH, Hicks MI, Fordtran JS. Studies on the
mechanisms of food-stimulated gastric acid secretion in normal
human subjects. J Clin Invest. 1976;58:623–631.
37. Murphy DW, Castell DO. Chocolate and heartburn: evidence of
increased esophageal acid exposure after chocolate ingestion. Am
J Gastroenterol. 1988;83:633–636.
38. Martinucci I, Guidi G, Savarino EV, et al. Vegetal and animal food
proteins have a different impact in the first postprandial hour of
impedance-pH analysis in patients with heartburn. Gastroenterol
Res Pract. 2018;2018:7572430.
39. Mone I, Kraja B, Bregu A, et al. Adherence to a predominantly
Mediterranean diet decreases the risk of gastroesophageal reflux
disease: a cross-sectional study in a South Eastern European popu-
lation. Dis Esophagus. 2016;29:794–800.
40. Nandurkar S, Locke GR 3rd, Fett S, Zinsmeister AR, Cameron AJ,
Talley NJ. Relationship between body mass index, diet, exercise
and gastro-oesophageal reflux symptoms in a community. Aliment
Pharmacol Ther. 2004;20:497–505.
41. Nam SY, Park BJ, Cho YA, et al. Different effects of dietary fac-
tors on reflux esophagitis and non-erosive reflux disease in 11,690
Korean subjects. J Gastroenterol. 2017;52:818–829.
42. Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary
habits and gastroesophageal reflux disease. World J Gastroenterol.
2009;15:1690–1701.
43. De Bortoli N, Tolone S, Savarino EV. Weight loss is truly effective
in reducing symptoms and proton pump inhibitor use in patients
with gastroesophageal reflux disease. Clin Gastroenterol Hepatol.
2015;13:2023.
44. Park SK, Lee T, Yang HJ, et al. Weight loss and waist reduction is
associated with improvement in gastroesophageal disease reflux
symptoms: a longitudinal study of 15,295 subjects undergoing
health checkups. Neurogastroenterol Motil. 2017;29:w13009.
45. Salyers WJ Jr, Mansour A, El-Haddad B, Golbeck AL, Kallail KJ.
Lifestyle modification counseling in patients with gastroesopha-
geal reflux disease. Gastroenterol Nurs. 2007;30:302–304.
46. Mutsekwa RN, Canavan R, Whitfield A, Spencer A, Angus RL.
Dietitian first gastroenterology clinic: an initiative to reduce wait
lists and wait times for gastroenterology outpatients in a tertiary
hospital service. Frontline Gastroenterol. 2019;10:229–235.
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